Comprehensive Clinical Documentation Improvement

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Situation

A safety net hospital system in New York State sought to elevate its clinical documentation improvement (CDI) program. The system, which has more than 500 inpatients beds and offers home health, long-term care and a multispecialty medical group, knew this would require an organization-wide transformation. The approach needed to be comprehensive, strategic and sustainable, and it required expert leadership in both CDI and change management.

Solution

The system partnered with Prism to target CDI program improvements in three core areas: securing the best and brightest clinicians and coders, engaging physicians and developing dashboards with core program metrics. The project:

• Heightened the system’s senior leaders’ understanding and involvement in CDI
• Improved CDI department recruitment and retention through an Advancement Ladder for Clinical Documentation Specialists
• Enhanced physician engagement through:
  • Education
  • Improved collaboration with physician queries
  • Reporting of physician specific metrics to highlight performance
  • Education
  • Greater physician leadership support
• Established consistent practice for all CDI team members across the system
• Implemented industry standard performance metrics
• Defined essential clinical indicators to prompt accurate physician documentation of critical diagnoses of Congestive Heart Failure and Sepsis
• Developed CDI department and physician dashboards

Partnering with Prism, the system significantly increased monthly financial reimbursement, CMI and CDI coverage rate.

“This collaborative CDI approach has been very effective at moving the needle and ensuring accurate capture of patient severity. We are positioned to meet the requirements of value-based payment programs and quality reporting transparency.”

System Chief Quality Officer